Integrating Physician Assistants in Canada

After several decades working in the Canadian military, Physician Assistants (PAs) are being introduced into provincial health care systems.

This year, Alberta launched a two-year demonstration project to integrate PAs into selected clinical practices. About a decade ago ago, PAs were introduced in Manitoba and Ontario.

In Ontario, PAs were part of Ontario’s broader health human resources strategy to give Ontarians “access to the right number and mix of qualified health care providers”.

The work of a PA is clear from their name – they support physicians in a wide range of health care settings. The decision about the extent of clinical work PAs can do is determined by the supervising physicians’ assessment of their clinical competencies, skills and experiences in a particular setting.

PAs are trained to take detailed medical histories, conduct physical exams, diagnose and treat some illnesses, order and interpret diagnostic tests, and counsel patients on preventative health. However, what PAs do in practice varies depending on the setting they work in, their experience and physician supervisor.

PAs work in many different settings – from hospital emergency departments and operating rooms to community family medicine practices.

The introduction of PAs has been hailed as important in ensuring better access to health care services through their role as a “physician-extender“. However, there are some outstanding questions about how PAs interact with other health care providers, and are integrated into the health care system.

Physician Assistants in practice

Unlike many other clinicians who practice independently, PAs work under the supervision of physicians. While PAs are a regulated health profession in Manitoba, they are not in Ontario and Alberta. Being an unregulated, non-autonomous health care provider means that a PA’s scope of practice is not defined in regulation.

Consequently, the work that PAs do is established through individual negotiations with a supervising physician or through framework agreements. Paramedics are another unregulated provider group in Ontario.

Robin Griller, executive director of the Inner City Family Health Team in Toronto says that a PA has been integrated into their practice to help reduce demands on physicians. Griller says this clears up time for the physicians to focus on caring for more complex patients. With a PA’s starting salary at $75,000, Griller says “it’s a cost effective way to manage physicians’ workload and time.”

The question of whether PAs are cost effective in Canada has not been studied. A 2011 economic analysis led by researchers at McMaster University described evidence around the cost effectiveness of PAs as anecdotal, and difficult to translate to the Ontario context.

Griller notes some of the challenges of integrating PAs into an interprofessional care team. He says that prior to introducing the PA into the Family Health Team, outreach and education around this role was done for other providers. “Everyone knows what a Nurse Practitioner or Social Worker does, but people are unclear about PAs and what they can and cannot do” he says.

Mary-Anne Robinson, CEO of the College & Association of Registered Nurses of Alberta outlines concerns with the regulation, scope and supervision of PAs.

“We are concerned about the impact on patient care and safety by virtue of creating a chaotic environment when you are introducing a new health care provider where no other professions understand what they do.” Robinson suggests that in the absence of clear guidelines of a PA’s scope of practice, patients’ safety is at stake. “There is a higher risk of error and adverse events in an environment where there isn’t good collaboration and it is unclear who is doing what” she says.

Maureen Taylor, a PA who has worked in Toronto’s Sunnybrook Health Sciences emergency department says that in spite of “press releases that unions and associations put out, we all care about patients.” Taylor says that this shared focus on providing patient care means “on the ground we [PAs] have good working relationships with nurses and NPs.”

History of Physician Assistants

PAs are a new, relatively small group of health care providers in Canada with about 300 currently in practice, mainly in Ontario and Manitoba. However, they are well established in the United States and the Canadian Forces.

In the United States there are more than 70,000 PAs working in both primary care and subspecialty practices alongside physicians. PAs were introduced in the years following the Vietnam War to address physician shortages and the need to increase access to health care in underserviced areas. Work as a PA also helped to employ soldiers returning from overseas who had been trained as medics.

In Canada, PAs were first introduced in the Canadian Forces to deal with the shortage of military physicians and have been working in that capacity since the 1970s.

However, it has only been in the past decade that PAs have been part of government strategies to mitigate a shortage of physicians and improve access to health care. PAs were first introduced into civilian practice in Manitoba in 1999 , Ontario in 2007 and just this year in Alberta.

When they were first introduced, the majority of PAs were trained in the Canadian Forces, the United States or were foreign-trained physicians. However, along with these demonstration projects have come PA training programs.

Training Physician Assistants

PAs in the Canadian Forces are trained alongside medics and other military health care providers. In the past decade, three civilian PA training programs have been introduced.

In Ontario, the University of Toronto, Northern Ontario School of Medicine and the Michener Institute for Applied Health Sciences have partnered in the Consortium of PA Education. This program offers a BScPA degree through the University of Toronto Faculty of Medicine, Department of Family and Community Medicine.

This program is a distance-education model and accepts 30 students per year. Maureen Gottesman, medical director of the program suggests distance learning is “an innovative, creative and cost effective” approach to training their student body, which are drawn from across the province. This is particularly important for remote and rural communities in Ontario, which face chronic physician shortages. Local community members trained as PAs have been seen as a possible sustainable approach to dealing with physician staffing challenges.

Gottesman suggests that training programs “have a responsibility and social accountability to ensure that grads have suitable jobs.” She says “we haven’t done the research – we all say that we’re responding to a health human resources planning need, but no one can tell me specifically where PAs are needed.”

The Ontario Ministry of Health and Long-Term Care tracks the number of PAs who work in jobs that are government-funded. However, Gottesman points out that these are only a portion of PAs working in Ontario.

Keeping track of PAs, their training and current employment is argued as being an important step in further integrating this provider into the health care system. Gottesman says a publicly accessible registry “would make people more comfortable and allay some fears and criticisms of PAs and what they do.”

The HPRAC recommendations, released in January 2013, stated that there is not enough evidence that the lack of self-regulation is causing patients harm. The recommendations supported this assertion by noting the relatively recent introduction of PAs, their small numbers and close physician supervision.

However, HPRAC did recommend that a compulsory registry for PAs be implemented under the oversight of the College of Physicians & Surgeons of Ontario.

Jill Hefley, Associate Director of Communications for the College of Physicians & Surgeons of Ontario says that while “the College has been supportive of the development of a registry for PAs “it is currently at the “discussion stage.” Because of this, Hefley was unable to provide an estimation of when such a registry would go live.

“Its just a list of names, which are not overseen or vetted in any way” she says, noting “this doesn’t meet the minimum requirements of regulation.” However such registries have been used for other unregulated health care provider groups, like personal support workers.

Chris Rhule, a Physician Assistant in Winnipeg and President of the Canadian Association of Physician Assistants also highlights regulation as a major barrier. He says that “integration [of PAs] is slowed down by regulation issues”.

In Manitoba, where Rhule practices, PAs are regulated through the College of Physicians & Surgeons. He says “regulation is key because then you don’t have to rely on medical directives for all of the delegation of duties … making it a lot less cumbersome in practice.”

“Regulation gives the public and other professionals comfort, security and safety to know that the profession has a body to report to” he says.

Rhule says that the major physician shortages at the time PAs were introduced helped galvanize support from the College and medical community. He says “having them on board helped influence government on legislative change.”

Plans for Alberta

There is currently no Alberta-based training program for PAs, and the majority of PAs in the province have been trained through the Canadian Forces.

Ten PA positions were introduced into locations deemed to have high needs across the province, including Milk River, Red Deer and Beaverlodge.

Mary-Anne Robinson questions the logic of introducing PAs in these communities. She says “registered nurses or nurse practitioners are underemployed professionals who are already regulated and autonomous” noting “it would make sense to have an autonomous provider rather than one who requires direct supervision from a physician, especially in communities where physicians are in short supply.”

Rollie Nichol, Associate Chief Medical Officer with Alberta Health Services has led the PA Demonstration Project. Nichol suggests that “we don’t see PAs competing with NPs – they have a different field of knowledge and different working relationships since NPs are designed for independent practice, but PAs are accountable to physicians.”

He points to the United States where NPs and PAs are both well established health care providers and “have found a way to have their own territory, and to collaborate.”

Nichol highlights that the PA Demonstration Project will undergo rigorous evaluation, and that the findings of this evaluation will inform future plans for PAs in Alberta. However, he frames the PA Demonstration Project within broader health system trends. “Finding alternative professionals or health care workers is happening everywhere in the system – it’s about finding the right provider at the lowest cost.”

This was such a well-researched article, the authors have really captured the progress and barriers PAs are facing for integration into Canada and across different jurisdictions. There is a lot of misinformation out there but Healthy Debate has done an excellent job reporting

Thank you for highlighting the need for more research into the cost-effectiveness/health economics of Physician Assistants. This is an issue thats been brought up several times and hopefully will be an issue taken up by CAPA.

– Where are PAs required? Are we training PAs for where they need to go?

Nurse Practitioners versus PAs:

%featured%Nursing associations have been expressing concern about the PA profession, but in practice, many of us have had collegial relationships with NPs. Many nurse practitioners faced many of the seam questions PAs do now when they were first introduced. Continuing to educate the public and advocating the profession will help clarify scope of practice and continue collaboration on patient care.%featured%

Thank you for also distinguishing difference in NP and PA education – although there is overlap in scope of practice especially in family medicine, internal medicine and Emergency Medicine – PAs practice in many specialty areas that you may not find NPs (e.g. surgical specialties such as Orthopaedics, Urology, etc.). I elaborate more here: http://bit.ly/19jZZZQ

%featured%Due to very limited stakeholder consultation in Alberta it appears to me that this initiative is a needless redundancy in Canadian health care at additional public cost. I remain unconvinced PAs are required if optimal deployment of Allied Health practitioners skill-sets were utilized by employers or prescribed by physicians%featured%. After all many of the allied health professions already assist physicians, how many assistants does one profession require to be more efficient?

Perhaps we should use the existing members of the allied health care team to full scope of practice before we begin adding more team members making collaborative practice even more challenging/disengaging.

Why do we need PAs? The first reason is lack of physicians, not other medical professionals which are over supplied. The skill sets and knowledge sets are quite different between PAs and other medical professionals, except MDs. Their training models determine it. The training model of PAs is medical model, very close to the training model of MDs. I need to mention that PAs training is shorter than MDs. Due to sharing same training model, PAs have the way better prepared to assist MDs than other medical professionals, like RNs, NPs, etc. The other allied health professionals are working with MDs to deliver the quality care for all of us. They are very important, but not directly assist MDs in MDs’ fields, like PAs. The second reason is to decrease the cost of delivering quality healthy care. The salary difference between MDs and PAs answer this.

The role established for the title PA has a broader basis for concern; that the PA can’t function without the doctor sanctioning their presence and role. The fact that the medical doctor and their regulatory body has no regulation over the Nurse Practitioner, or any nurse…but they do have control over the PA leaves the PA’s role in jeopardy.

Which professional would you rather have assess you…one that is regulated and has an established role that is complementary to the role of the doctor or one that is “the handmaiden role” to the doctor? For years nurses struggled to have their own role and identity “out from the clutches” of the medical profession which they rightly earned and for which they have much respect.The NP role which is an extended nursing function role enables this designated professional to accomplish and carry out many any and more functions that the PA.

The doctors got tired of fighting to keep control of nurses so they decided to make a role for someone they could control.

Nursing is for nurses. Nurses should not be practicing medicine. You are misguided and your hubris is concerning.

The fact that some nurses, such as yourself, want to get “out from the clutches” of the medical profession is concerning, because it appears that since these people could not, or chose not to, undergo the rigorous training of medical school and residency that rewards one with the privilege and responsibility of being patient care leaders, they are instead trying to obtain such a role through legislation.

It is akin to saying that because flight attendants spend a lot of time in airplanes they should be allowed to fly the plane, pilot training be damned.

It is a well-documented fact that 50% of nurses in the “doctor of nurse practitioner” degree programs in the states failed an abridged version of the USMLE step III examination, which all residents pass with nary a day studying for it. Not to mention the admissions standards for nursing are nowhere near as strict as those of medicine.

In closing, nursing training does not supply one with the knowledge base to practice medicine in a safe manner. If a nurse wants to get “out from the clutches” of the medical profession, they should apply to medical school. If they cannot due to academic mediocrity, then they have no business practicing medicine at all.

Guess the editors didn’t like my reference to a historical figure.. got deleted. I think that Dr. Avery’s analogy to pilots and stewardess is classic and absolutely telling. “I am the pilot , you are the servant/hostess”. (nurse) Well Dr. Avery , FYI , NP’s are not aspiring to be physicians but rather they are aspiring to provide patients with some of the aspects of care that physicians have claimed as their sole domain and entitlement. NP’s do not buy into the myth that MD’s are a superior race, we do not wish to “fly the plane” as you would put it. I have total respect for the dedication and training my physician colleague posseses but at the same time he respects my abilities and experience and we work together to provide our patients with the best care we can. He doesn’t see my as the subordinate stewardess and himself as the superior glorious pilot. On “flights” , he trusts that while he is doing difficult and severe tasks that only his training prepares him for , I am doing other complex tasks that I have returned to advanced education to learn that keep that plane flying and keep the passengers feeling like we are in this together and on a strong team.

I disagree that NPs “are not aspiring to be physicians.” I think the recent midwifery Ontario Human Rights complaint requesting pay equity with family physicians is a sign of things to come and an incremental encroachment on the scope of practice for primary care physicians.

While expansion of other health professions such as NPs, PAs, pharmacists and midwifery broadens the primary care base and leads to more options for patients, which is good, it also seems to inadvertently be replacing family physicians with cheaper, less educated (or at least less focused / less intensely educated) labour without much of a discussion on the appropriate division of duties.

As a family physician myself whom works hard already and feels that much of what I do is already unappreciated, undervalued or simply unpaid, I worry that any further time and financial pressures by competition with other professions may lead my practice to becoming unsustainable and forcing me to leave general practice.

My experience so far working with NPs is that they have been enthusiastic, dedicated and hard-working, but I have also had some big concerns over their base of clinical knowledge, clinical decision making and inefficient use of resources such as diagnostic testing and referrals due to the former. As independent practitioners, it was difficult for me to collaboratively care for these patients with NPs, as I often had serious qualms with their clinical reasoning and decisions, but as solo practitioners, found it difficult how to approach these conflicts with patients and colleagues.

Unfortunately as well, I was concerned that the expansion of scope of practice of NPs in Ontario seemed to have progressed to the point that they were almost indistinguishable from my own privileges and abilities. However, they were cheaper, more readily available for hire and more willing to work as a subordinate to an employer, decreasing the need for MDs like myself.

In this environment, my desire to practice a full scope of primary care medicine was reduced to being asked to only taking care of patients with chronic pain on narcotics, difficult to manage complex patients and patients with severe mental issues while the rest of the healthy or average patients were cared for by others. This ultimately was undesirable, taxing and unfulfilling or me and ultimately lead me to have to resign.

I am sorry that you have felt you had to resign under the stress of managing the complex health needs of your clients/patients. What you raise as an issue for you, that you feel others such as NP’s, midwives are entrenching the field for PCP’s is not the way this should be. It is my belief and it has been known for some time, that those who wish to serve a broader base of clients in the health care file need extended practice qualifications so they could assist patients who wanted and needed services when GP’s or PCP’s couldn’t service either for time or other reasons.
It is is true that patients need to have choice of partitioner under certain conditions whether it is appropriate to do so but it has never been the intention for one to replace that of another, yet i get the feeling this is what is happening to you and perhaps others like you.
The purpose of having a well rounded and integrated health team practice is to allow patients and practitioners work together and to have the right service for the right patient. The bigger problem historically has been that there was not enough integrated family practices where “a team of regulated professionals” could properly service patients and share the work load and have a team effort to provide the best service to the patients for whom they serve.There is sometimes an agreement in principle but something in the management or set-up isn’t working well. I have a physician who is part of a wonderful team practice and they have a NP, midwife, social worker, pharmacy consultant and others who all help the patient and work as part of a team where they share the work load and mange the patient’s individual needs.It seem to me that your burden of complex cases is not well managed because there isn’t a “team approach” and rather each person is fending for themselves which must also not be very good for the patient?

Your hubris is equally irritating. I am “not” a nurse practitioner, but I can assure you that, contrary to what you “feel” or “believe” NP’s practice and are appreciated where they are needed, and moreover, they are not practising medicine, they are practising an advanced level of nursing that allows them to practice within a scope of practice beyond a regular nursing program. You might say they have done a “residency” program to achieve a level of educations and practice skills in the way doctors may take a residency in internal medicine or some other speciality beyond graduating from medicine and internship. They also work very well with doctors who do have respect for what they’ve been educated to provide their patients and patients also appreciate having NP’s or they’d request to only see the doctor.
As a nurse I never wanted to be a doctor or I’d have chosen that profession. As I see it, the professions are complementary, not competitive. One is not better than the other. Only those who work well together to serve their patients are valued by those whom they serve and not for their title.

Thank you, sir, for posting what is not politically correct, but which is absolutely true. Having worked with both NPs and PAs, I will take the latter anyday. NPs scope of practice does not match the poor training they have (I’ve been a clinical supervisor for NP training programs), with too few hours, too few patient exposures and an approach that is not well suited to diagnosis and treatment. PA’s can work independently but collegially in a team; NPs always want to stress ‘how different their model of practice is’. Thanks again!

Yikes, that’s a pretty narrow way of looking at PAs. PAs practice medicine and increase the number of well-trained hands on deck to treat patients. Depending on the experience of the PA and the clinical context he or she is working in, PAs are far from ‘handmaidens’ and can have a lot of autonomy (not necessarily direct supervision when appropriate), helping to treat more patients.

%featured%This isn’t about nurses. Or doctors. It’s about patients. We can surely agree that having more well-prepared practitioners is better than not having them.%featured%

%featured%I have many concerns about an unregulated and small body of health care providers. Who is ensuring that they are up-to-date in practising evidence based care? the busy physician who “supervises” them?%featured% It is great where you have an individual who takes responsibility for their own learning needs and takes the initative for learning but what about those who don’t ? where is the standardization? besides most RNs can do all these “tasks” that the PAs are doing 9and then some). why are we complicating things

If there was a Pan Canadian Assessment Process convened similar to what all professions are supposed to undertake since 2004 many questions like this one would already be answered.There is a voluntary continuing competency program, MAINPRO created by a national organization which has no legislative mandate that I can find to enforce such a program. It is undergoing some changes evidently.

I suppose it is better than nothing, however, it does contribute to the confusion about standards being promulgated throughout the country. What is the standard? What is the level of compliance? What are the implications of non participation? Who legally enforces non compliance orders? So many questions so few thoughful answers provided to date.

If anybody can provide a copy of the Pan Canadian Entry to Practice Credentials Assessment Report on Physicians Assistants it might help collaboration amongst the parties impacted.

If you look at the submissions from nursing unions to HPRAC when it considered PA regulation, they argued that regulation for PAs was unnecessary, as there was no evidence that patient safety was at risk because PAs were well supervised by physicians. %featured%Now that HPRAC and the Ontario Minister of Health agreed with that assessment, the nursing unions across the country once again use lack of regulation to state that PAs are unsafe. What hypocrisy. PAs ASKED to be regulated.%featured% We are ready to put our educations and skills up against any other profession. And yes, we are trained in the medical model and work alongside physicians and we do more than just “tasks”. Nurse practitioners don’t want to be considered assistants to physicians – great! There’s enough work for everyone, and physician assistants are here to stay.

Heather,
I am a Physician Assistant from the US and all these concerns would be alleviated if you would research the profession. The information is available to anyone concerned regarding our background. Prior to admission to PA school we must complete a Bachelor’s of Science degree. The PA program is a graduate program which is highly selective in choosing candidates, and only top graduates are accepted. For example, my class had over 1200 applicants for 45 seats. We also require an average of 2000 hrs of medical volunteer time prior to admission. We are then trained in the “medical model”. By this, I mean we are trained by physicians in each specialty. We are responsible to pass Board Exams at the completion of our studies similar to the medical boards. We are also responsible for continuing education yearly and maintaining current evidence based practice guidelines. Unlike NPs, the PA is required to retest every 6 years to maintain their license, which requires us to stay current. We follow the AMA (American Medical Association) guidelines, which have just moved to a 10 year retesting cycle and so the PA profession followed accordingly. I am one of the PAs here in Alberta as part of the demonstration project for our profession. I make it a point to inform all my patients who I am and what role I play on the healthcare team. To date, all of my patients have been very appreciative of the care they received and thanked me immensely for being a part of their care.
Donna Kuzmiski PA-C, MPAS

Wow Elizabeth this has to be one of the most uneducated responses I have seen about another health profession in a while. As a practicing PA I find it offensive to infer that I practice in a “handmaiden role” or that physicians control my practice. Maybe you should educate yourself on my profession and then comment.
It would like me saying that NPs are unsafe in that their program is lacking clinical exposure and focuses mostly on research therefore they do not have the training to see patients independently. Also what scares physicians about the NP role is that after 2 years of training they feel they can replace physicians in most instances. This is not about physicians controlling anyone it is about patient safety. Having the ability to perform 80% of a physician role is one thing, the issue here is that the other 20% is where patients are put at risk.
I am a strong advocate for all health professions and have worked with some outstanding NP’s throughout my career. I am hopeful that those who are trying to undermine one health profession to self-promote their own buy using patient safety as leverage would think, read and then comment.
Lastly you should think about the countless Canadian Forces PA’s who have and continue to deploy all over the world, providing quality care in some of most challenging environments.

FYI NP’s study much longer than 2 years, unless you refer to a two year program post a four year BScN program or four plus two for a masters of nursing and then a two year post grad course for NP designation. Now, how long is the PA program?

As a newly practicing PA in Ontario I think that Healthy Debate has done a great job summarizing the tremendous progress the profession has made since its initiation. Furthermore, I believe that this article captures the major barriers facing our profession currently. Nevertheless, as with most Canadian articles regarding our profession, I am always disappointed to read the numerous hostile comments posted by misinformed individuals (although the number seems to be decreasing as a whole). I hope that with time, you will be fortunate enough to work with a PA in order to clarify some of your misconceptions.

As a PA, I have the privilege to be working in a fabulous team comprised of Nurses, NPs, and Physicians. Over the last few years, I have realized that the majority of these hostile remarks are often posted online behind the protection of ones computer screen. I have found that in practice, all of these professions can AND DO work together synergistically to provide optimal care to patients within a timely manner. We are entering an era where mid-level providers are becoming the standard. There is no longer a single solution to help and meet the demand of our aging population.

Trained in the medical model, PAs are highly educated health professionals. Although we applied for regulation, we were rejected, as we were not thought to meet the “risk for harm”. Nevertheless, we all choose to write a licensing exam and partake in CME to remain well informed. Furthermore, must I remind everyone that the Nursing unions were one of the groups recommending PAs NOT be regulated? Yet are the ones bashing us for not practicing safely? I joined this profession in order to practice medicine and provide care to our population. In the current state, I find that there is still a huge shortage of HCPs and departments are under stress to fill this gap. Rather than fighting impending change, I would recommend that you embrace it. An antagonistic attitude will only get you so far in a multidisciplinary health care system.

Question : when a patient phones the office for an appt are they told they will be seeing you or the MD ? The Doctor’s office I go to always says ‘your appt is with Dr X ‘ but when you arrive at the office you find out you are seeing the PA . Kind of a bait and switch . I don’t know if he is afraid that if the receptionist tells the patient they will be seeing the PA that they will refuse . And this is most unfair to the PA as some people will make it plain that they expected to see the Doctor and got fobbed off on a substitute . Aside from hanging a paper on the wall back in the office area the Doctor has done nothing to introduce this man to his patients . As well , when I spoke with the Office nurse about my concerns she said that the Doctor considers a visit with the PA equal to a visit with him but apparently will not let the Receptionist tell you who you will be seeing when you phone for an appointment.

Just to provide some accurate information and not just unsupported retoric to the debate.

%featured%There are many different professions recognized in Canada by different organizations at a National level providing Patient Care yet do not have a “Regulated” framework. An example would be Paramedics that are not regulated in all provinces but perform controlled acts under the direction of a Medical Director – a Physician. For years I work with Nurse Practitioners who were not regulated by the Province in Alberta, most of what they did was covered under the Nursing Act but until 1999 and then with many admendments formalized in 2005. They were safe and competent. %featured% They also were more interested in patient care then signing petitions or listening to people saying you are not qualified. They worked despite the system’s rules, but they also worked in a team with Physicians, Psychologists, Social Workers and even non regulated professionals. Ontario with the oldest NP program McMaster – which actually had to shut for a while for multiple reasons including politics – formally regulated their profession in 2005. The practice of individuals without regulation is still an issue, however that does not mean it is not controlled. It is a format and structure of rules but never an absolute that a regulated profession is actually safer than any other, how could it be?

Ontario whose Medical Act was drafted in the 1880′s I believe has been revised many times but has a provision for deligated acts as does Alberta. Where the responsibility is the Physicians who has the oversight and responsibility but the authority to delligate to their agent tasks and procedurtes. Manitoba regulated in 1999 -which defines the process for Physician Assistants and their employment – long before PAs began to work in the Province in 2003-2004. NPs not regulated until 2005 yet worked in Manitoba since the 1990′s at least.

The requirement to follow the medical orders of the agent of the Physician has been long established in common law across the Commonwealth and the United States. The concept predates most modern day Regulations and is the foundation of Deligated Authority. That does not neglate the responsibility to question if an order from a Physician or Agent is unclear or perhaps unsafe, but it does place patient safety at risk if not obey because of some turff war that harms patient care. If a NP writes an in-patient prescription or provides a medical order for years it was a local by-law or hospital policy; regulations provides a structure, not absolute authority. Neither PAs nor NPs can write orders on just anyone. They must have an established judiciary reponsibility of care. The PA-MD practice model provides that. The concept with a PA is they are providing care for their Physicians’s patient under that physician’s direction.

The Physician Assistant Profession predates the Nurse Practitioner profession, Why? Because when Eugene Stead at Duke University in North Carolina asked the Nursing Profession to expand their practice to assume responsibility they said no for almost ten years. The Nurses who did did more and learnt other “non traditional nursing” tasks were ostracized, locally and nationally by the American Nursing Association. The battle should not be on titles or half baked philosophy but what is best for the patients. Many programs in the US in the 1970′s and 80 shared a class room, NP and PA, stoped becasue Nursing stated they would teach their own, no physicians need apply. (North Dakota, Stanford, Palo Alto, etc) A difference in philosophy, many strongly disagree with.

Canadian PAs have a National Competancy Profile that defines scope of Practice and the entry to practice qualifications. There is a code of ethics, national certification exam (which predates the NP national exam BTW), requirements for continous professional development and a national growing appreciation for what is being offered by the PA profession. The World Health Organization recognizes PA and NP and mid-wife reporting that outcomes are the same as with physicians. To paraphrase “it is suppose to be about the patient dummy!” Qualified compent provided care is always superior to highly educated non-delivered theoritical care.

The Physician Assistant Model works and has since its orginal concept with “sick-birth attendants” of the Royal Navy (Loblloly Boys) It is a global concept. Get use to it! Let us focus on finding a way to optimize patient care using all the resources in manner that is economical and efficient. PAs are safe and patients benefit from Physician-team directered care. They and our health system will never benefit from turff wars.

As someone quoted in the article and given some of the comments that have been made, I would like to add two things:

1. Integrating a PA into our team has been a pretty smooth process: it does require some community engagement with the rest of the team (non-physician and physician, clinical and administrative), but this engagement has been beneficial to the functioning of our multi-disciplinary team as it has helped to further build collaborative work practices across the whole team and shared understandings of everyone’s roles, not just the PA.

It is so helpful that I would encourage FHTs, CHCs and other teams to undertake in-team community engagement processes around roles whether they have a PA or not!

2. I would say that our experience is that NPs, RNs and PAs can all work effectively and easily together — they have different and complementary roles. Yes, there is some overlap, but that kind of overlap exists already and is nothing new or problematic. It is just part of the reality of *any* workplace that involves multiple role types.

From my perspective, issues arise when organizations (employers, professional associations, etc.) intervene in an attempt to protect their ‘turf’, not from the work of the variety of disciplines.

I really would hope that the challenges faced in creating respectful and accepting space in our healthcare system for NPs have taught us that turf protection is counter-productive.

It would be nice to see us work to further integrate and respect the work of different practitioners, organizations and staff groups within the broader health care system — regulated and non-regulated, clinicians and administrators, hospital and community.

I know we usually take the high road and provide comments like many of those today. But seriously, the PA profession has been around for 35 years in the States/Canadian Forces and it’s been ten years since we started working in the civilian world here in Canada. Just how long will it be until some people take their heads out of the sand? For once … I’m going to say I question the judgment of someone that jumps to conclusions or screams the sky is falling, the sky is falling.

Thankfully the real judge of our competency is our co-workers, the patients we treat and the confidence those people have in us. That confidence and trust does not come from a Cracker Jack box. I wonder what these people must think after having been treated by, or worked along side a PA only to at some point in time to read that we are menace to society or that we should be banished from the planet. How do they reconcile the fact that they have found us to be professional/competent/knowledgeable and caring???

Do you think they go – OMG I was treated by a witch doctor??? Really???

Ok I’m done and like most of us I will just keep doing what we have been doing (in my case over 30 years) providing care to patients. As an FYI ….In all that time I have never shaken a rattle over a patient or thrown bones on the ground…

By the way…for those unaware… providing care the “under the supervision of a physician” does not necessarily mean in the same office… it means we have a formal relationship in which we can seek and receive guidance when required. (Not being thrown to the wolves is a good thing) When I was with the Forces the Docs that “supervised me”… were often not even in the same hemisphere…they were however available for consultation or to provide advice when necessary. (Another good thing)

“A professional is someone who has completed formal education and training in one or more profession. The term also describes the standards of education and training that prepare members of the profession with the particular knowledge and skills necessary to perform the role of that profession. In addition, most professionals are subject to strict codes of conduct enshrining rigorous ethical and moral obligations. Professional standards of practice and ethics for a particular field are typically agreed upon and maintained through widely recognized professional associations. Some definitions of professional limit this term to those professions that serve some important aspect of public interest [1] and the general good of society”

Sounds like the PAs and NPs I have worked with…. So the issues are clearly not with those of us in the trenches…. I wonder where the real issues are?

A UBC research synthesis released earlier this year, and funded by MSFHR, found merits to the introduction of Physician Assistants but after a comprehensive review and plan of regulatory, interprofessional and funding factors.

We already have Nurse Practitioners who are regulated, well trained mid level providers. Physician assistants are the MD’s unions solution to turf protection and maintaining total control of the health care system. Next thing, they will try to obtain prescribing authority for PA’s or create an “Obstetrical PA” specialty to usurp the role of the Midwife. Widespread PA implementation will jeopardize the available NP position funding and put the majority of provincial health care dollars under control of MD’s. NP’s are autonomous self regulated health professionals who work collaboratively with MD’s but are not supervised by them. Its entirely political and I feel sorry for the PA ‘s and prospective PA students who are certainly well meaning people who want to serve their communities but are being used as a tool by the MD unions.

I don’t agree that Renal Colic’s comments are ridiculous and offensive. I agree with her position that the Role of NP and PA has been subjected to the whims of medical politics. For years the role of the NP was difficult to get established and then maintained because the government would okay funding to establish the programming only to cut it off so for years the position was in limbo. I expect the funding is now more stable and will likely be for the role of PA, at least one hopes this is the case.

Also I completely agree with the concerns of PA’s being unregulated, but do we not have to start somewhere? Look how nurses began, and now look how far they have come. I think with time, they will have specific standards they will have to meet to maintain their PA license. Also, as a physician I’m positive they are committed to continual learning to keep their license as well, and as they learn they will pass down their knowledge to the PA’s.

Overall I think this is a positive change for the healthcare system in Canada. And as the population grows we need a more diverse healthcare system that’s able to cope and adapt to work the health care demands of the community.

They are well trained medical professionals and in my opinion, they provide a much better care with even much caution, especially as they know they are under supervision of a physician. In the United States today, most patients prefer that a physician assistant attend to them than a full fleshed MD.
They are payed way too small compared to what they do, so why not regulate them health professionals?

I am actually applying to PA programs right now in the States (where I’m currently doing my undergrad). It’s a master program so, like the NP, I will have 6 years of schooling too. However, a small distinction can be made between the two. PA’s are trained in the Medical Model, and NP’s on the Nursing model. What does this mean? What this means is that the PA has had some different courses than the NP. This may include undergraduate pre-requisites that include a year of General inorganic Chemistry, a year of Organic Chemistry, Biochemistry, a year of Physics, microbiology and molecular biology. These are typically not courses hat nurses take. Why don’t they take them? Because the Nursing model isn’t designed for pathophysiology. the NP model is based on patient education, health promotion, prevention and wellness. NP’s will also pick a specialty to practice as well and usually stay in that speciality (women’s health, family, paediatric, gerontology are quite common). Some practice in Surgery but this isn’t very common. The actual time requirements are different too.

It is required for NP’s to have been an RN first. This gives them plenty of real world hours with patients before going on to get their NP. NP School averages 500 Didactic Hours, and around 500-700 Clinical hours before licensure.

Most PA programs require 1000-3000 Hours of patient care before starting but this can range from being a phlebotomist, EMT etc.) The didactic portion of PA school is 1000 hours and then 2000 hr’s of clinical rotations in the same specialties that Doctors do rotations. The whole model for PA developed from a shortage of Family Doctors and that is the role they were intended to fulfill. In fact, they were trained initially using the same model that the Army used to fast track training of Doctors during WW2. In addition, PA’s and Med students take some of the same classes from the same professors.

The biggest distinction that I feel is trying to be made here is about autonomy. NP’s have a defined scope of practice. There are benefits to that and drawbacks. They are limited in what they can do, but also have the freedom to practice as they please. There is a growing number of PA’s who are opening up their own clinics in the US with a business partner (the MD/DO) acting as their “Supervising Physician”. This usually works close to some like 95% owned by PA and 5% by MD but varies from State to State. The PA essentially practices medicine on their own, and has the Dr. available in case something that he doesn’t know comes up, in the which case he asks the Dr. who may or may not know more on the subject.

To finish this giant post, I’ll just say that I think both professions are great. There is a great need for highly trained, cost effective, family practitioners and PA’s and NP’s fill this role as many new Doctors are not going into family practice. In my preparation for my interviews, I’ve read countless articles (peer reviewed and will gladly post them if you wish) about the effectiveness of PA’s and NP’s. The results of those studies? That PA’s AND NP’s provide similar care to that of Physicians and pose no more risk to patients than a Doctor.

My own motivation for becoming a PA is because I like being able to switch specialties without having to do a residency (though residencies are available to PA’s). I’m interested in Family Practice, working in the ER, and being 1st Assist in Surgeries and will get to do all as a PA. The bickering needs to stop between the two professions though. There is room at the table for all. To ask which one is better or more prepared or poses the greater threat to patients is a worthless pursuit.
Sorry for this ridiculously long post, I just wanted the facts out there.

My Family Doctor has recently brought a Physician Assistant into his practice . My concern with tis is that when you phone the office for an appt ,you are told your appt is with th eDoctor . If there is a ‘reminder’ call it is that you have an appt with Dr X at such and such a time . Only when you arrive at the office do you find out that you are seeing the Physician Asst and that this was the plan all along . Also when you see the Doctor ,you see the Office Nurse before and she weighs you , takes your Bp etc but if you see the Physician Asst , you do not see the nurse . So the visits are not equal in scope . When I spoke with the Office Nurse ,whom I have known for years , she said that the Doctor considers seeing him or seeing the Physician Asst as being ‘equal’ .And that patients have a choice as to who they will see. Government Propaganda ! A visit with a doctor who has been in practice for 20 yrs and a visit with a PA newly arrived in Canada with ‘not up to par’ language skills are never going to be equal . I don’t know if the receptionist is instructed to say that all visits are with the Doctor because he is afraid that if patients are told beforehand ,they will cancel the appt .

Good points all around BUT…there are a lot of people that require medical attention. There is enough need for ALL medically trained people…from the PSW and HCA to NP and PA…quit squabbling over the politics, jockeying for position and work together. There is a need and a role for everyone.

My husband is a PA. He met with derision, hostility and resistance (from nurses) when he started at our local hospital. After five years…and a possible end to his employment…everyone is upset and dreading the loss of “Their PA”

I love how this was a post about PAs and it quickly turned into a nurse/NP bashing fest.
There are, however, some things I would like to address.

1) What’s actually the point of a PA?
I have worked in emerg with PAs and I am not really sure what the point is? Because they have to be “closely” supervised by MDs, they go, assess the patient and then spend more time than they took assessing the patient, talking to the physician about their assessment and clinical ideas. The time would have been spent better having the MD go and assess the patient and make a diagnosis! I feel like the idea of a PA is better than the praxis, as, in practice, the PA consumes a lot of time from the physician.

2) Stop comparing PAs to NPs
It’s frustrating. We aren’t the same and we shouldn’t be researched and compared to each other. In fact, I have seen PAs work under an NPs license. If the NP can be the “supervisor” for a PA, then it is hardly fair to compare them as secondary practitioners. They are different, they have different education, they have different roles and they have different scopes of practice (PAs completely lacking a scope of practice to begin with).

3) Nurses think they don’t practice medicine
This is equally as frustrating as PAs being compared to NPs. I am so embarrassed to see nurses like Elizabeth Rankin, who proudly flaunts her BScN status, but lacks complete insight into the profession in which she works. Nurses have embedded propaganda into their curriculum that basically is there to make themselves feel better. Things like “nursing theories” and “nursing models” and how it is completely different than “medical models”. Wake up call nurses, you can be fed this propaganda as much as you want, in the end you are learning human anatomy, pharmacology, pathophysiology, diagnoses and management of illness etc. which is MEDICINE! You can call it what you want, add some “nursing theories” in there to make it seem like its not medicine, but it’s medicine. Get over it. Accept it. You wonder why physicians don’t take you serious? It’s because you pretend to be something you are not.

4) There’s a lot of idiot NPs out there. Just like there is a lot of idiot doctors.
Yes, there are tons of horror stories of idiot NPs who make mistakes and make sketchy judgements. Just like there are tons of horror stories of how surgeons removed the wrong limb during an amputation and that malpractice suits against physicians alone could fund all NP education in Canada for many years to come. Don’t use your specific interactions with NPs as a generalized basis. Yes, idiots exist. But you don’t see me bringing up the fact that it took 8 doctors before an NP finally realized I had a pituitary adenoma.

5) Be civil.
Like it or not, we are all in this together and we are all going to work together. Don’t trash each other’s profession because your personal views on these professions will not change the ministry of health’s decision. As much as I don’t like PAs, I see that the research supports their utility and efficacy and so I accept them as a player in the primary health care role, because I am SMART ENOUGH to recognize my opinion accounts for nothing in the whole world that is Canadian and US healthcare.

7) If MDs created PAs for control, the same is true for nurses with PSWs and CNAs.
It is extremely hypocritical for nurses to accuse MDs of creating PAs so that they could have control as nurses did the same with PSWs, who are also unregulated. Smarten up nurses, you can’t have it both ways. Nurses like this make me ashamed of my profession.

Early PAs were IMGs who were not licensed to practice in Canada. They had to pass a test of competency and were granted the ability to practice as a PA. This was partly how the government was able to prove the PA model, along with Canadian Forces and American PAs that practiced in Canadian healthcare. I’m not sure if that happens much anymore now that there are educational programs.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.